Amer Harky1,2 MRCS, Rebecca
Abdelmalak3 BSc, Francesco Torella
FRCS1,2, Mark Field FRCS1,2
- Faculty of Health and Life Sciences, University of Liverpool, UK
- Liverpool Cardiovascular Surgery, Liverpool Heart and Chest Hospital,
Liverpool, United Kingdom
- Imperial College School of Medicine, Faculty of Medicine, Imperial
College London, London, UK
CorrespondenceAmer Harky MRCS
Liverpool Cardiovascular Surgery
Liverpool Heart and Chest Hospital
Liverpool, UK
E-mail: aaharky@gmail.com
Tel: +44-151-600-1616Funding: noneConflict of interest: noneKey words: Aortic dissection, Marfan, COVID-19
Dear Editor,
We read with interest the published article by Ikeda et
al. [1], they performed thoracic endovascular aortic repair (TEVAR)
in a patient with Marfan syndrome (MFS) for acute complicated type B
aortic dissection (TBAD) during COVID-19 pandemic.
The evidence around TEVAR for MFS is scarce and open repair remains the
gold treatment[2]. During the COVID-19 pandemic, many patients are
either being denied treatment or given inferior options on the basis of
age, comorbidities and risk of COVID pneumonia; however, the guidelines
for aortic intervention in the United Kingdom have remained largely
unchanged from pre-COVID-19 era [3]. Our questions to the authors
relate to whether their solution was an unnecessary compromise. There is
no clear indication defined in their case as a cold leg doesn’t
necessary means an ischaemic limb. The TEVAR procedure performed aiming
to minimise hospital stay, yet this approach may have put the patient at
higher risk of developing paraplegia and visceral organ malperfusion,
while compromising her long-term care.
There is need to clarify if she had risk factors that prone her to a
higher risk acquiring severe COVID-19 which necessitated deviating from
the traditional open surgery recommended for MFS patients with TBAD
[2]. The authors did not report on renal function, evidence of bowel
malperfusion or whether there was resistant hypertension that needed
immediate intervention. If the need to expediate intervention was the
fear of limb ischaemia, is it conceivable a femoro-femoral bypass could
have saved the limb and definitive open surgery on her aorta could have
been performed at a later stage, especially since she was
haemodynamically stable.
Moreover, as Marfan-diseased aortas are prone to further dilatation, we
believe their justification for opting for endovascular repair should
also have been more balanced, exploring the know high rate of long-term
TEVAR-associated complications in MFS patients including endoleaks,
retrograde dissection, stent-graft-induced new entry tears, surgical
conversions and reintervention. There is also need for imaging follow-up
to assess the success of TEVAR and early detection of aforementioned
complications.